Fill and Sign the Curriculum Vitae Sample in Fiji Form

EXHIBIT O: SAMPLE* ELIGIBILITY FILE LAYOUT AND DATA DICTIONARY April 2011 FILE-AID 9.2.0 PRINT FACILITY 11:24:52 PAGE 1 RECORD LAYOUT REPORT - RECORD LAYOUT DATASET : DM.IMSVSA.COPYLIB - MEMBER : DM16101N -------- FIELD LEVEL/NAME ---------- --PICTURE-FLD START END LENGTH -------------------------NOTES---------------------N101-HIPAA-EXTRCT-RECORD 1 1270 1270 N21-NTC-TYPE-NUM, N21-AU-PRCS-CD, N21-CL-SYPSTD-DT from prior record layout NOT represented in new layout -5 N101-HCI-TRN-REAS-CD XX 07 = client disenrolled/ineligible 1 1 2 08 = client enrolled/eligible 09 = client monthly roster record -5 N101-HCI-SORT-KEY N/A -5 N101-CL-AU-HOH-REL-CD -5 N101-CL-HOH-ID-NUM -5 N101-CL-ID-NUM -5 N101-CL-FIRST-NAME -5 N101-CL-MIDDLE-INIT -5 N101-CL-LAST-NAME -5 N101-CL-SEX-CD -5 N101-CL-PRIM-LANG-CD -5 N101-CL-SSN-NUM -5 N101-CL-DOB-DT -5 N101-AU-RES-STRT-1-ADDR -5 N101-AU-RES-STRT-2-ADDR -5 N101-AU-RES-CTY-ADDR -5 N101-AU-RES-ST-CD -5 N101-AU-RES-ZIP-ADDR -5 N101-LOC-IDENT-GRP AU = Assistance Unit - 10 N101-AU-CURR-TWN-CD - 10 N101-AU-CURR-DO-NUM -5 N101-AU-RES-TELEPHONE-NUM - 10 N101-AU-RES-TEL-AREA-NUM - 10 N101-AU-RES-TEL-NUM -5 N101-AU-MAIL-STRT-1-ADDR -5 N101-AU-MAIL-STRT-2-ADDR -5 N101-AU-MAIL-CTY-ADDR -5 N101-AU-MAIL-ST-CD -5 N101-AU-MAIL-ZIP-ADDR 2 X 2 99 = control record 3 3 1 XX 9(9) 9(9) X(12) X X(19) X X 9(9) 9(8) X(55) X(55) X(22) XX 9(9) GROUP 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 4 6 15 24 36 37 56 57 58 67 75 130 185 207 209 218 5 14 23 35 36 55 56 57 66 74 129 184 206 208 217 222 2 9 9 12 1 19 1 1 9 8 55 55 22 2 9 5 999 99 GROUP 999 9(7) X(55) X(55) X(22) XX 9(9) 19 20 21 22 23 24 25 26 27 28 218 221 223 223 226 233 288 343 365 367 220 222 232 225 232 287 342 364 366 375 3 2 10 3 7 55 55 22 2 9 * Final layout may include additional fields (e.g., client cell phone number). -5 N101-AR-FIRST-NAME AR = Authorized representative -5 N101-AR-MIDDLE-INIT -5 N101-AR-LAST-NAME -5 N101-AR-RES-STRT-1-ADDR -5 N101-AR-RES-STRT-2-ADDR -5 N101-AR-RES-CTY-ADDR -5 N101-AR-RES-ST-CD -5 N101-AR-RES-ZIP-ADDR -5 N101-AR-RES-TELEPHONE-NUM - 10 N101-AR-RES-TEL-AREA-NUM X(12) 29 376 387 12 X X(19) X(55) X(55) X(22) XX 9(9) GROUP 999 30 31 32 33 34 35 36 37 38 388 389 408 463 518 540 542 551 551 388 407 462 517 539 541 550 560 553 1 19 55 55 22 2 9 10 3 - 10 N101-AR-RES-TEL-NUM -5 N101-CL-MANC-STS-VNDR-NUM 999999999 = Fee for service 9(7) 9(9) 39 40 554 561 560 569 7 9 enrolled in Managed Care/PCCM -5 N101-PLAN-CVRG-DESCP-GRP GROUP 41 - 10 N101-AU-MA-CVRG-GRP-CD XXX 42 - 10 N101-AU-PROG-TYPE-CD X 43 - 10 N101-CL-UI-TYPE-CD XX 44 - 10 N101-CL-MANC-STS-REAS-CD GROUP 45 15 N101-CL-MANC-STS-CD X 46 15 N101-FILLER-002 XX 47 - 10 N101-CL-AU-STS-REAS-CD XXX 48 - 10 N101-CL-DCF-CAT-CD X 49 - 10 N101-CL-DCF-EFF-DT 9(8) 50 » -24 NOV 2010 FILE-AID 9.2.0 PRINT FACILITY RECORD LAYOUT REPORT - RECORD LAYOUT DATASET : DM.IMSVSA.COPYLIB - MEMBER : DM16101N -------- FIELD LEVEL/NAME ---------- --PICTURE-FLD - 10 N101-CL-DCF-SVC-RCVD-CD X 51 - 10 N101-CL-RACE-1-CD X 52 - 10 N101-CL-RACE-2-CD X 53 - 10 N101-CL-RACE-3-CD X 54 - 10 N101-CL-RACE-4-CD X 55 - 10 N101-CL-RACE-5-CD X 56 - 10 N101-CL-HSP-LATN-ETH-IND X 57 - 10 N101-RENEWAL-DT X(8) 58 - 10 N101-WVR-TYPE-CD X 59 - 10 N101-INST-TYPE-CD XX 60 - 10 N101-FILLER-011 X(11) 61 -5 N101-CL-MANC-EFF-DT 9(8) 62 -5 N101-CL-TPL-POLICY-INFO(1) OCCURS 5 TIMES GROUP 63 - 10 N101-CL-TPL-CARR-NUM(1) X(5) 64 - 10 N101-CL-TPL-CARR-NAME(1) X(25) 65 - 10 N101-CL-TPL-PLCY-EFF-DT(1) X(8) 66 - 10 N101-CL-TPL-PLCY-EFF-END-DT(1) X(8) 67 - 10 N101-CL-TPL-PLCY-INDIV-NUM(1) X(13) 68 Vendor ID if 570 570 573 574 576 576 577 579 582 583 11:24:52 619 572 573 575 578 576 578 581 582 590 50 3 1 2 3 1 2 3 1 8 PAGE 2 START 591 592 593 594 595 596 597 598 606 607 609 620 END 591 592 593 594 595 596 597 605 606 608 619 627 LENGTH 1 1 1 1 1 1 1 8 1 2 11 8 628 628 633 701 632 657 74 5 25 658 665 8 666 673 8 674 686 13 * Final layout may include additional fields (e.g., client cell phone number). - 10 N101-CL-TPL-PLCY-GRP-NUM(1) X(15) 69 -5 N101-CL-TPL-POLICY-INFO(2) GROUP 63 - 10 N101-CL-TPL-CARR-NUM(2) X(5) 64 - 10 N101-CL-TPL-CARR-NAME(2) X(25) 65 - 10 N101-CL-TPL-PLCY-EFF-DT(2) X(8) 66 - 10 N101-CL-TPL-PLCY-EFF-END-DT(2) X(8) 67 - 10 N101-CL-TPL-PLCY-INDIV-NUM(2) X(13) 68 - 10 N101-CL-TPL-PLCY-GRP-NUM(2) X(15) 69 -5 N101-CL-TPL-POLICY-INFO(3) GROUP 63 - 10 N101-CL-TPL-CARR-NUM(3) X(5) 64 - 10 N101-CL-TPL-CARR-NAME(3) X(25) 65 - 10 N101-CL-TPL-PLCY-EFF-DT(3) 66 X(8) - 10 N101-CL-TPL-PLCY-EFF-END-DT(3) X(8) 67 - 10 N101-CL-TPL-PLCY-INDIV-NUM(3) X(13) 68 - 10 N101-CL-TPL-PLCY-GRP-NUM(3) X(15) 69 -5 N101-CL-TPL-POLICY-INFO(4) GROUP 63 - 10 N101-CL-TPL-CARR-NUM(4) X(5) 64 - 10 N101-CL-TPL-CARR-NAME(4) X(25) 65 - 10 N101-CL-TPL-PLCY-EFF-DT(4) X(8) 66 » -24 NOV 2010 FILE-AID 9.2.0 PRINT FACILITY RECORD LAYOUT REPORT - RECORD LAYOUT DATASET : DM.IMSVSA.COPYLIB - MEMBER : DM16101N -------- FIELD LEVEL/NAME ---------- --PICTURE-FLD - 10 N101-CL-TPL-PLCY-EFF-END-DT(4) X(8) 67 - 10 N101-CL-TPL-PLCY-INDIV-NUM(4) X(13) 68 - 10 N101-CL-TPL-PLCY-GRP-NUM(4) X(15) 69 -5 N101-CL-TPL-POLICY-INFO(5) GROUP 63 - 10 N101-CL-TPL-CARR-NUM(5) X(5) 64 - 10 N101-CL-TPL-CARR-NAME(5) X(25) 65 - 10 N101-CL-TPL-PLCY-EFF-DT(5) X(8) 66 - 10 N101-CL-TPL-PLCY-EFF-END-DT(5) X(8) 67 - 10 N101-CL-TPL-PLCY-INDIV-NUM(5) X(13) 68 - 10 N101-CL-TPL-PLCY-GRP-NUM(5) X(15) 69 -5 N101-CL-LAST-NAME-SUFX X(10) 70 -5 N101-AR-LAST-NAME-SUFX X(10) 71 -5 N101-CL-FRST-NAME-PRFX X(10) 72 687 702 702 707 701 775 706 731 15 74 5 25 732 739 8 740 747 8 748 760 13 761 776 776 781 775 849 780 805 15 74 5 25 806 813 8 814 821 8 822 834 13 835 850 850 855 849 923 854 879 15 74 5 25 880 887 8 11:24:52 PAGE 3 START END LENGTH 888 895 8 896 908 13 909 924 924 929 923 997 928 953 15 74 5 25 954 961 8 962 969 8 970 982 13 983 998 1008 1018 997 1007 1017 1027 15 10 10 10 * Final layout may include additional fields (e.g., client cell phone number). -5 -5 - 73 74 75 76 1028 1038 1038 1046 1037 1067 1045 1053 10 30 8 8 77 78 79 80 81 82 83 84 1054 1068 1077 1089 1090 1109 1119 1129 1067 1076 1088 1089 1108 1118 1128 1129 14 9 12 1 19 10 10 1 85 1130 1135 6 86 87 88 1136 1145 1180 1144 1179 1269 9 35 90 89 1180 1180 1 90 1181 1190 10 91 1191 1192 2 92 1193 1222 30 93 1223 1224 2 94 1225 1229 5 95 1230 1239 10 96 1240 1247 8 97 1248 1249 2 98 -5 99 » -24 NOV 2010 FILE-AID 9.2.0 PRINT FACILITY RECORD LAYOUT REPORT - RECORD LAYOUT DATASET : DM.IMSVSA.COPYLIB - MEMBER : DM16101N -------- FIELD LEVEL/NAME ---------- --PICTURE-FLD *** END OF LAYOUT REPORT *** 1250 1270 1269 1270 20 1 -5 -5 -5 -5 -5 -5 -5 -5 -5 -5 -5 - N101-AR-FRST-NAME-PRFX X(10) N101-TRN-ID-NUM GROUP 10 N101-BTCH-CYC-DT 9(8) 10 N101-TRN-SEQ-NUM 9(8) Will contain record count for control record 10 N101-FILLER-014 X(14) N101-VNDR-FED-TAX-NUM 9(9) N101-AU-HOH-FIRST-NAME X(12) N101-AU-HOH-MIDDLE-INIT X N101-AU-HOH-LAST-NAME X(19) N101-HOH-LAST-NAME-SUFX X(10) N101-HOH-FRST-NAME-PRFX X(10) N101-EOFAM-IND X N/A N101-PROG-SRC X(6) N/A N101-AU-NUM 9(9) N101-FILLER-035 X(35) N101-PCCM-GRP GROUP N/A 10 N101-PCCM-PRVDR-NM-QUAL-TYP X N/A 10 N101-PCCM-PRVDR-NM-ID X(10) N/A 10 N101-PCCM-PRVDR-REL-CD XX N/A 10 N101-PCCM-PRVDR-CITY-ADDR X(30) N/A 10 N101-PCCM-PRVDR-ST-CD XX N/A 10 N101-PCCM-PRVDR-ZIP-CD X(5) N/A 10 N101-PCCM-PRVDR-TEL-NUM X(10) N/A 10 N101-PCCM-PRVDR-EFF-DT X(8) N/A 10 N101-PCCM-PRVDR-CHG-REAS-CD XX N/A 10 N101-FILLER-020 X(20) N101-EOR-CON X 11:24:52 START PAGE END 4 LENGTH DATA DICTIONARY 1 * * * * * * * * DB/DC DATA DICTIONARY REPORT * Final layout may include additional fields (e.g., client cell phone number). 11/24/10 11:24:31 STRUCTURE REPORT FOR: SEGMENT 0DESC: HIPAA EXTRACT RECORD. 0CATEGORY SEQATTR REL KEYWORD PAGE:0001 AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME ________________________________________________________________________________ ________________________________________ ELEMENT 00001/0 WITH AC HCI-TRN-REAS-CD 0 DEN=0465 CODE DENOTING THE RECORD TYPE CODE ---- DESCRIPTION -------------------------- ---------------------------------------07 08 09 99 ELEMENT 00003/0 WITH ELEMENT 00004/0 WITH CLIENT DISENROLLED CLIENT ENROLLED CLIENT MONTHLY RECORD CONTROL RECORD AC HCI-SORT-KEY 0 SORT FIELD NO LONGER USED. 0 = HOH 1 = NON-HOH AC CL-AU-HOH-REL-CD 0 TO HEAD OF HOUSEHOLD. RELATIONSHIP OF THE CLIENT TO THE HEAD OF THE DEN=0021 CLIENT'S RELATIONSHIP PHYSICAL OR ADOPTIVE HOUSEHOLD. THIS INFORMATION IS USED THROUGHOUT THE SYSTEM FOR ONLINE NON-FINANCIAL AND FINANCIAL ELIGIBILITY. ---------------------------------------CHILD OF HEAD OF HOUSEHOLD) EDITS AND FOR PERFORMANCE OF CODE ---- DESCRIPTION -------------------------- AU AUNT OR UNCLE(DEPENDENT CH CP FC CHILD (DEPENDENT CHILD) CHILD WHO IS A PARENT FIRST COUSIN (DEPENDENT GC GRAND/GREAT-GRAND CHILD OR HS HALF-SIBLING (DEPENDENT NN NIECE/NEPHEW, GRAND/GREAT NS NON-PARENT SPOUSE (SPOUSE CHILD) STEPCHILD (DEPENDENT CHILD) CHILD) NIECE/NEPHEW (DEP CHILD) OF HOH WHO IS NOT A PARENT) * Final layout may include additional fields (e.g., client cell phone number). UNRELATED GUARDIAN 1 * * * * * * * * OC OTHER CHILD - RELATED OR OP OR OU PW OTHER PARENT OTHER RELATED ADULT OTHER UNRELATED ADULT PENDING WARD LEGAL DB/DC DATA DICTIONARY REPORT STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME 11/24/10 11:24:31 PAGE:0002 ________________________________________________________________________________ ________________________________________ CHILD) HOH WHO IS ALSO A PARENT) ELEMENT 00006/0 WITH IDENTIFICATION NUMBER. ELEMENT 00015/0 WITH SC STEPCHILD (DEPENDENT SE SI SP HEAD OF HOUSEHOLD/SELF SIBLING (DEPENDENT CHILD) SPOUSAL PARENT (SPOUSE OF SS STEP-SIBLING (DEP CHILD) WD WARD LEGAL GUARDIAN AC CL-HOH-ID-NUM 1 CLIENT HEAD OF HOUSEHOLD AC CL-ID-NUM 1 UNSIGNED CL-ID-NUM CL-ID-NUM OCC 1 IN EMS FOR A CLIENT. REFERENCE THE UNIQUE IDENTIFIER GENERATED THIS DATA ELEMENT IS A PRIMARY KEY TO THE CLIENT DATABASE. ELEMENT 00024/0 WITH THE CLIENT. IF THE CLIENT HAS NO FIRST AC CL-FIRST-NAME 0 THE FIRST NAME OR GIVEN NAME OF NAME, THE CLIENT'S NAME IS ENTERED IN THE CLIENT LAST NAME FIELD AND ENTERED ON THE 'MEMB' SCREEN IN SCREENING SCREEN IN THE INTERACTIVE INTERVIEW. NAME IS INITIALLY ENTERED ON THE 'NAME' ELEMENT 00036/0 WITH MIDDLE NAME THIS FIELD IS LEFT BLANK. CLIENTS NAMES ARE INITIALLY AND ARE UPDATED ON THE 'DEM1' THE HEAD OF HOUSEHOLD'S FIRST SCREEN IN SCREENING. AC CL-MIDDLE-INIT 0 THE FIRST LETTER OF THE CLIENTS * Final layout may include additional fields (e.g., client cell phone number). ELEMENT 00037/0 WITH AC CL-LAST-NAME 0 REFUGEE OR OTHER PERSON HAS NO FIRST USED TO CAPTURE THE PERSON'S NAME (AS FIRST NAME FIELD). ELEMENT 00056/0 WITH SURNAME OF THE CLIENT. WHEN A NAME, THE LAST NAME FIELD IS OPPOSED TO USING THE CLIENT AC CL-SEX-CD 0 DEN=0083 ---------------------------------------- CODE ---- CLIENT'S SEX CODE. DESCRIPTION -------------------------- F FEMALE M MALE AC CL-PRIM-LANG-CD 0 ELEMENT 00057/0 WITH DEN=0205 CODE DENOTING THE PRIMARY LANGUAGE READ/SPOKEN BY THE HEAD OF HOUSEHOLD. INDICATES WHETHER ALL CLIENT NOTICES FOR THIS ASSISTANCE UNIT SHOULD BE WRITTEN IN SPANISH. THIS DATA ELEMENT ONLY APPLIES TO THE HEAD OF UNIT. ANY VALUE OTHER THAN "S-SPANISH" IN ENGLISH. THE NAME AND THE ADDR SCREENS. THE HOUSEHOLD FOR THE ASSISTANCE CAUSES THE NOTICES TO BE PRINTED THIS INFORMATION IS ENTERED ON CODE ---- DESCRIPTION -------------------------- ---------------------------------------1 * * * * * * * * DB/DC DATA DICTIONARY REPORT STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME 11/24/10 11:24:31 PAGE:0003 ________________________________________________________________________________ ________________________________________ A B C E F G H I K L N ARABIC BOSNIAN CREOLE ENGLISH FRENCH GERMAN HMUNG ITALIAN KYMER LAOTIAN ALBANIAN * Final layout may include additional fields (e.g., client cell phone number). O PORTUGUESE P POLISH R RUSSIAN S SPANISH U KURDISH V VIETNAMESE X OTHER Z FARSI AC CL-SSN-NUM 1 ELEMENT 00058/0 WITH ALTERNATE PICTURE (UNPACKED, UNSIGNED) OF CL-SSN-NUM NUMBER OF THE CLIENT. THIS IS THE CLIENT'S MAY OR MAY NOT BE EQUAL TO THE NUMBER RECEIVE SOCIAL SECURITY BENEFITS. ASSIGNED BY THE SOCIAL SECURITY THE SOCIAL SECURITY ACCOUNT OWN SOCIAL SECURITY NUMBER AND UNDER WHICH THE CLIENT MAY SOCIAL SECURITY NUMBERS ARE ADMINISTRATION OF THE FEDERAL GOVERNMENT. ELEMENT 00067/0 WITH AC CL-DOB-DT 1 ALTERNATE PICTURE OF CLIENT'S DATE OF BIRTH. ELEMENT 00075/0 WITH FORMAT IS CCYYMMDD AC AU-RES-STRT-1-ADDR 1 AU RESIDENCE STREET ADDRESS 1 AC AU-RES-STRT-2-ADDR 1 ELEMENT 00130/0 WITH AU RESIDENCE STREET ADDRESS 2 AC AU-RES-CTY-ADDR 0 ELEMENT 00185/0 WITH RESIDENTIAL CITY NAME. THE ASSISTANCE UNIT'S THIS CITY WOULD THE TOWN CODE ASSOCIATED WITH ELEMENT 00207/0 WITH VALUE WITH "CT" UNTIL OTHERWISE CHANGED. ---------------------------------------- * * * * * * * * THIS ADDRESS. AC AU-RES-ST-CD 0 OF THE AU. IT RESIDES ON THE ADDRESS 1 BE THE SAME AS REPRESENTED BY DEN=0004 RESIDENCE STATE CODE SCREEN. THE SYSTEM PREFILLS THE CODE ---- DESCRIPTION -------------------------- AK ALASKA AL ALABAMA AR ARKANSAS AZ ARIZONA CA CALIFORNIA DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0004 * Final layout may include additional fields (e.g., client cell phone number). STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME ________________________________________________________________________________ ________________________________________ 1 * * * * * * * * CO COLORADO CT CONNECTICUT CZ CANAL ZONE DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MS MISSISSIPPI MT MONTANA NC NORTH CAROLINA ND NORTH DAKOTA NE NEBRASKA NH NEW HAMPSHIRE NJ NEW JERSEY NM NEW MEXICO NV NEVADA NY NEW YORK OH OHIO OK OKLAHOMA OR OREGON PA PENNSYLVANIA PR PUERTO RICO RI RHODE ISLAND SC SOUTH CAROLINA SD SOUTH DAKOTA TN TENNESEE TX TEXAS UT UTAH VA VIRGINIA VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSION DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0005 * Final layout may include additional fields (e.g., client cell phone number). STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME ________________________________________________________________________________ ________________________________________ WV WEST VIRGINIA WY WYOMING AC AU-RES-ZIP-ADDR 1 ELEMENT 00209/0 WITH ALTERNATE PICTURE (UNPACKED, UNSIGNED) OF AU-RES-ZIP-ADDR ASSISTANCE UNIT RESIDENCE ZIPCODE. ELEMENT 00218/0 WITH AC LOC-IDENT-GRP 0 TOWN CODE AND CURR DISTRICT NUMBER ELEMENT 00001/0 CONTAINS AC AU-CURR-TWN-CD 1 IDENTIFIES FOR HIPAA THE CURR DEN=0237 (UNSIGNED) OF AU TOWN CODE ALTERNATE PICTURE THE RESIDENTIAL ADDRESS TOWN NUMBER OF THE TOWN IN WHICH THE ASSISTANCE AU-TWN-NUM, THE ASSISTANCE UNIT'S TOWN NUMBER IS CARRIED UNIT CURRENTLY RESIDES. THIS FIELD IS REDUNDANT WITH THE RESIDENTIAL TOWN ADDRESS. THE REDUNDANTLY ON THE AU-ID-SEGMENT FOR PERFORMANCE REASONS. TOWN NAME ---------------- CODE ---- TOWN NAME ---------------- GRISWOLD 115 PROSPECT GROTON 116 PUTNAM GUILFORD 117 REDDING HADDAM 118 RIDGEFIELD HAMDEN 119 ROCKY HILL HAMPTON 120 ROXBURY HARTFORD 121 SALEM HARTLAND 122 SALISBURY HARWINTON 123 SCOTLAND HEBRON 124 SEYMOUR CODE TOWN NAME CODE ---- ----------------- ---- 001 ANDOVER 058 002 ANSONIA 059 003 ASHFORD 060 004 AVON 061 005 BARKHAMSTEAD 062 006 BEACON FALLS 063 007 BERLIN 064 008 BETHANY 065 009 BETHEL 066 010 BETHLEHEM 067 * Final layout may include additional fields (e.g., client cell phone number). - KENT 125 SHARON KILLINGLY 126 SHELTON KILLINGWORTH 127 SHERMAN LEBANON 128 SIMSBURY LEDYARD 129 SOMERS LISBON 130 SOUTHBURY LITCHFIELD 131 SOUTHINGTON LYME 132 SOUTH WINDSOR MADISON 133 SPRAGUE MANCHESTER 134 STAFFORD MANSFIELD 135 STAMFORD MARLBOROUGH 136 STERLING MERIDEN 137 STONINGTON MIDDLEBURY 138 STRATFORD MIDDLEFIELD 139 SUFFIELD MIDDLETOWN 140 THOMASTON MILFORD 141 THOMPSON MONROE 142 TOLLAND MONTVILLE 143 TORRINGTON MORRIS 144 TRUMBULL 011 BLOOMFIELD 068 012 BOLTON 069 013 BOZRAH 070 014 BRANFORD 071 015 BRIDGEPORT 072 016 BRIDGEWATER 073 017 BRISTOL 074 018 BROOKFIELD 075 019 BROOKLYN 076 020 BURLINGTON 077 021 CANAAN 078 022 CANTERBURY 079 023 CANTON 080 024 CHAPLIN 081 025 CHESHIRE 082 026 CHESTER 083 027 CLINTON 084 028 COLCHESTER 085 029 COLEBROOK 086 030 COLUMBIA 087 031 CORNWALL 088 UNION DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0006 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 0CATEGORY RC SUBJECT NAME SEQATTR REL KEYWORD NAUGATUCK 145 1 * * * * * * * * ________________________________________________________________________________ ________________________________________ NEW BRITIAN 146 VERNON NEW CANAAN 147 VOLUNTOWN NEW FAIRFIELD 148 WALLINGFORD 032 COVENTRY 089 033 CROMWELL 090 034 DANBURY 091 * Final layout may include additional fields (e.g., client cell phone number). NEW HARTFORD 149 WARREN NEW HAVEN 150 WASHINGTON NEWINGTON 151 WATERBURY NEW LONDON 152 WATERFORD NEW MILFORD 153 WATERTOWN NEWTOWN 154 WESTBROOK NORFOLK 155 WEST HARTFORD NORTH BRANFORD 156 WEST HAVEN NORTH CANAAN 157 WESTON NORTH HAVEN 158 WESTPORT NORTH STONINGTON 159 WETHERSFIELD NORWALK 160 WILLINGTON NORWICH 161 WILTON OLD LYME 162 WINCHESTER OLD SAYBROOK 163 WINDHAM ORANGE 164 WINDSOR OXFORD 165 WINDSOR LOCKS PLAINFIELD 166 WOLCOTT PLAINVILLE 167 WOODBRIDGE PLYMOUTH 168 WOODBURY POMFRET 169 WOODSTOCK PORTLAND 170 OUT OF STATE PRESTON ELEMENT 00004/0 CONTAINS OFFICE OR REGION OFFICE THAT ADMINISTERS ---------------------------------------- 035 DARIEN 092 036 DEEP RIVER 093 037 DERBY 094 038 DURHAM 095 039 EASTFORD 096 040 EAST GRANBY 097 041 EAST HADDAM 098 042 EAST HAMPTON 099 043 EAST HARTFORD 100 044 EAST HAVEN 101 045 EAST LYME 102 046 EASTON 103 047 EAST WINDSOR 104 048 ELLINGTON 105 049 ENFIELD 106 050 ESSEX 107 051 FAIRFIELD 108 052 FARMINGTON 109 053 FRANKLIN 110 054 GLASTONBURY 111 055 GOSHEN 112 056 GRANBY 113 057 GREENWICH 114 AC AU-CURR-DO-NUM 2 DEN=0117 THE CURRENT DISTRICT THE CASE UNIT, ALTERNATE FORMAT. CODE ---10 11 DESCRIPTION -------------------------HARTFORD MANCHESTER * Final layout may include additional fields (e.g., client cell phone number). 20 NEW HAVEN 30 BRIDGEPORT 31 DANBURY 32 STAMFORD 33 NORWALK 40 NORWICH 41 WILLIMANTIC 42 KILLINGLY 50 MIDDLETOWN 51 MERIDEN 52 NEW BRITAIN 60 WATERBURY 61 BRISTOL 62 TORRINGTON 1 * * * * * * * * DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0007 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 0CATEGORY RC SUBJECT NAME SEQATTR REL KEYWORD ________________________________________________________________________________ ________________________________________ ELEMENT 00223/0 WITH 99 CENTRAL OFFICE AC AU-RES-TELEPHONE-NUM 0 AU RESIDENCE TELEPHONE NUMBER GROUP ITEM ELEMENT 00001/0 CONTAINS AC AU-RES-TEL-AREA-NUM 1 ASSISTANCE UNIT, ANOTHER FORMAT. ELEMENT 00004/0 CONTAINS AC AU-RES-TEL-NUM 1 THE TELEPHONE AREA CODE OF THE HEAD OF HOUSEHOLD RESIDENCE PHONE NUMBER ELEMENT 00233/0 WITH ELEMENT 00288/0 WITH ELEMENT 00343/0 WITH HOUSEHOLD MAILING ADDRESS ELEMENT 00365/0 WITH HEAD OF HOUSEHOLD MAILING ADDRESS. ---------------------------------------- REF OCC 0 FOR PACKED FORMAT AC AU-MAIL-STRT-1-ADDR 1 AU MAILING ADDRESS STREET 1 AC AU-MAIL-STRT-2-ADDR 2 AU MAILING ADDRESS STREET 2 AC AU-MAIL-CTY-ADDR 0 CITY NAME OF THE HEAD OF GJ 05/13 AC AU-MAIL-ST-CD 0 DEN=0004 CODE ---AK THE STATE CODE FOR THE DESCRIPTION -------------------------ALASKA * Final layout may include additional fields (e.g., client cell phone number). AL ALABAMA AR ARKANSAS AZ ARIZONA CA CALIFORNIA CO COLORADO CT CONNECTICUT CZ CANAL ZONE DC DISTRICT OF COLUMBIA DE DELAWARE FL FLORIDA GA GEORGIA GU GUAM HI HAWAII IA IOWA ID IDAHO IL ILLINOIS IN INDIANA KS KANSAS KY KENTUCKY LA LOUISIANA MA MASSACHUSETTS MD MARYLAND ME MAINE MI MICHIGAN MN MINNESOTA MO MISSOURI MS MISSISSIPPI 1 * * * * * * * * DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0008 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 0CATEGORY RC SUBJECT NAME SEQATTR REL KEYWORD ________________________________________________________________________________ ________________________________________ MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESEE TEXAS UTAH VIRGINIA * Final layout may include additional fields (e.g., client cell phone number). ELEMENT 00367/0 WITH UNSIGNED) OF AU-MAIL-ZIP-ADDR HOUSEHOLD MAILING ADDRESS ELEMENT 00376/0 WITH REP, DATA ABOUT WHOM WAS ENTERED IN ELEMENT 00388/0 WITH VI VIRGIN ISLANDS VT VERMONT WA WASHINGTON WI WISCONSIN WV WEST VIRGINIA WY WYOMING AC AU-MAIL-ZIP-ADDR 1 ALTERNATE PICTURE (UNPACKED, ZIPCODE FOR THE HEAD OF AC AR-FIRST-NAME 0 THE FIRST NAME OF AN AUTHORIZED SCREENING. AC AR-MIDDLE-INIT 0 THE MIDDLE INITIAL OF AN AUTHORIZED REPRESENTATIVE, DATA ABOUT WHOM ELEMENT 00389/0 WITH ELEMENT 00408/0 WITH ELEMENT 00463/0 WITH ELEMENT 00518/0 WITH ELEMENT 00540/0 WITH ELEMENT 00542/0 WITH ELEMENT 00551/0 WITH WAS ENTERED IN SCREENING. AC AR-LAST-NAME 0 AC AR-RES-STRT-1-ADDR 1 AU RESIDENCE STREET ADDRESS 1 AC AR-RES-STRT-2-ADDR 1 AU RESIDENCE STREET ADDRESS 2 AC AR-RES-CTY-ADDR 0 AC AR-RES-ST-CD 0 AREP STATE CODE AC AR-RES-ZIP-ADDR 0 AC AR-RES-TELEPHONE-NUM 0 AUTHORIZED REPRESENTATIVE RESIDENT TELEPHONE NUMBER GROUP ITEM. ELEMENT AC AR-RES-TEL-AREA-NUM 0 00001/0 CONTAINS 1 * * * * * * * * DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0009 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 0CATEGORY RC SUBJECT NAME SEQATTR REL KEYWORD ________________________________________________________________________________ ________________________________________ ELEMENT 00004/0 CONTAINS ELEMENT 00561/0 WITH AC AR-RES-TEL-NUM 0 AC CL-MANC-STS-VNDR-NUM 1 * Final layout may include additional fields (e.g., client cell phone number). THE CLIENT'S MANAGED CARE PROVIDER VENDOR NUMBER OR 999999999 if none. ELEMENT AC PLAN-CVRG-DESCP-GRP 0 00570/0 WITH COVERAGE DESCRIPTION FOR HIPAA. THESE IS MADE UP OF EMS DATA ONLY FOR THE PURPOSE OF THE TRANSLATER AND EMS FIELDS WHICH MAY OR MAY NOT BE USED AT A LATER DATE. ELEMENT AC AU-MA-CVRG-GRP-CD 0 00001/0 CONTAINS DEN=0115 CODE DENOTING THE MEDICAL ASSISTANCE COVERAGE GROUP ASSIGNED BY EMS FOR AN AU. EACH COVERAGE GROUP HAS ITS OWN ELIGIBILITY DETERMINATION POLICIES THAT ARE USED TO DECIDE WHETHER THE AU IS ELIGIBLE FOR MEDICAL SERVICES. ALL ELIGIBLE MEDICAL SERVICES CLIENTS MEET THE ELIGIBILITY CRITERIA FOR AT LEAST ONE OF THE MEDICAL ASSISTANCE COVERAGE GROUPS. THE CODE IS 3 BYTES LONG WITH THE FIRST CHARACTER INDICATING THE THE CATEGORY OF COVERAGE. ---------------------------------------- CHILDREN CODE ---- DESCRIPTION -------------------------- A02 C02 D01 D02 CADAP ASSISTANCE CONNPACE ASSISTANCE HUSKY A FOR DCF CHILDREN STATE MEDICAL FOR DCF D03 MEDICAID FOR DCF NON-IVE D04 MEDICAID FOR CHILD LEAVING D05 BEHAVIORAL HEALTH FOR NON- F01 AID TO FAMILIES WITH F02 F03 POST-AFDC EARNINGS L30 HUSKY EXTENSION FOR THOSE F04 HUSKY EXTENSION FOR CHILD F05 MEDICAID - WORK F06 HUSKY A PRESUMPTIVE F07 F08 HUSKY A FOR FAMILIES MEDICAID FOR CHILD CARE F09 MEDICAID - NOT ELIGIBLE SUB ADOPTED CHILD FOSTER CARE HUSKY CHILD DEPENDENT CHILDREN - AFDC WITH EARNINGS SUPPORT RECIPIENTS SUPPLEMENTATION ELIGIBILITY RECIPIENTS FOR AFDC * Final layout may include additional fields (e.g., client cell phone number). CHILDREN CHILDREN UNDER AGE 1 EXTENSION MEDICAID 1 TO 5 HUSKY NEEDY FAMILIES ADULTS (LIA) ADULTS EXTENSION ADULTS PILOT PROGRAM 1 * * * * * * * * F10 HUSKY A FOR NEWBORN F11 HUSKY A FOR NEWBORN F12 F13 HUSKY A FOR YOUNG ADULTS MEDICAID FOR CHILDREN F14 TRANSACTIONAL WORK F20 MEDICAID FOR CHILDREN AGES F25 F26 HUSKY A FOR CHILDREN CONTINUOUS OR GUARANTEED F95 HUSKY A FOR MEDICALLY F99 G02 HUSKY A FAMILY SPENDDOWN MEDICAID FOR LOW INCOME G03 MEDICAID FOR LOW INCOME G05 MEDICAID FOR LOW INCOME DB/DC DATA DICTIONARY REPORT STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME 11/24/10 11:24:31 PAGE:0010 ________________________________________________________________________________ ________________________________________ ADULTS ADULTS SPENDDOWN RECEIVING HOME CARE FAMILIES (MN) TERM CARE (CN) AGED/BLIND/DISABLED LONG TERM CARE EXTENSION EXTENSION SCREENING MEDICAL CARETAKER ADULTS - FACILITY G07 MEDICAID FOR LOW INCOME G99 MEDICAID FOR LOW INCOME H01 HUSKY FOR CHILDREN H99 HOMECARE WIAVER FOR L01 MEDICAID FOR ADULT LONG L99 MEDICAL NEEDY M01 CATEGORY NEEDY PREGNANCY M02 MEDICAL NEEDY PREGNANCY M03 STATE PRE-ADMISSION M04 REPATRIATED CITIZEN M05 DEPENDENT STUDENT N01 MEDICAID FOR LOW INCOME * Final layout may include additional fields (e.g., client cell phone number). ADULTS - FACILITY SERVICES BENEFICIARIES BENEFICIARIES ASSISTANCE REFUGEES N99 MEDICAID FOR LOW INCOME P01 P02 P05 CATEGORY NEEDY PREGNANT PREGNANT 185 POVERTY LEVEL PREGNANCY 133 RELATED P95 P99 Q01 HUSKY A FOR PREGNANT WOMEN PREGNANT WOMEN SPENDDOWN QUALIFIED MEDICARE Q03 SPECIFIED MEDICARE Q04 Q05 R01 UNDER 135% OF POVERTY UNDER 175% OF POVERTY REFUGEE CASH AND MEDICAL R02 MEDICAID EXTENSION FOR R03 R04 MEDICAID FOR REFUGEES (CN) MEDICAID FOR REFUGEE R95 R99 MEDICAL FOR REFUGEES (MN) MEDICAID SPENDDOWN FOR S01 AID TO THE AGED, BLIND OR S02 MEDICAID TO AGED, BLIND OR S03 MEDICAID - NOT ELIGIBLE S04 MEDICAID FOR EMPLOYED S05 MEDICAID FOR EMPLOYED S95 MEDICAID TO AGED, BLIND OR S99 MEDICAID SPENDDOWN T01 CARETAKER OR CHILD IN LONG T99 CARETAKER OR CHILD IN LONG W01 MEDICAID HOME CARE WAIVER W99 MEDICAID HOME CARE WAIVER NEWBORNS REFUGEES DISABLED - AABD DISABLED (CN) FOR AABD DISABLED DISABLED DISABLED (MN) AGED,BLIND OR DISABLED TERM CARE TERM CARE FOR ADULTS (CN) FOR ADULTS (MN) ELEMENT 00004/0 CONTAINS DERIVED FROM THE AU-PROG-TYPE-CD FIELD RELATIONSHIP. --------------------------------------- AC AU-PROG-TYPE-CD 0 DEN=0114 THIS IS DUPLICATE DATA OF THE RELATED AU FOR THIS CL/AU CODE ---- DESCRIPTION -------------------------- * Final layout may include additional fields (e.g., client cell phone number). AGED/BLIND/DISABLED AGED/BLIND/DISABLED STAMP 1 * * * * * * * * A OLD AGE - AID TO B BLIND - AID TO C PUBLIC ASSISTANCE - FOOD DB/DC DATA DICTIONARY REPORT STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD 11/24/10 11:24:31 PAGE:0011 AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME ________________________________________________________________________________ ________________________________________ AGED/BLIND/DISABLED ASSISTANCE STAMPS AND NON-PUBLIC ASSISTANCE FOOD STAMPS CITIZEN ELEMENT 00005/0 CONTAINS CLIENT'S UNEARNED INCOME SOURCE. DETERMINATION OF FINANCIAL ELIGIBILITY ASSISTANCE UNIT. D DISABLED - AID TO E F G I J M IV-E MEDICAL ASSISTANCE FAMILY MEDICAL ASSISTANCE REFUGEE MEDICAL ASSISTANCE SAGA INDIVIDUAL SAGA COUPLE MISCELLANEOUS MEDICAL N P R S NON-RECURRING PREGNANT - AFDC AFDC - REGULAR NON-PUBLIC ASSISTANCE FOOD T MIXED PUBLIC ASSISTANCE U Y AFDC - UNEMPLOYED RECURRING REPATRIATED 1 TYPE 1 CADAP 2 TYPE 2 CADAP 3 TYPE 3 CADAP AC CL-UI-TYPE-CD 0 DEN=0038 CODE IDENTIFYING THIS INFORMATION IS USED IN THE AND BENEFIT LEVEL FOR THE IT APPEARS ON THE 'UINC' SCREEN. SEE THE UNEARNED INCOME MATRIX FOR INFORMATION ABOUT WHICH UNEARNED WHICH ASSISTANCE PROGRAMS AND COVERAGE INCOME TYPES ARE COUNTABLE FOR GROUPS. ---------------------------------------- CODE ---AL AN DESCRIPTION -------------------------ALIMONY ANNUITIES * Final layout may include additional fields (e.g., client cell phone number). DUPLICATE READY STIPEND BL CO CS DA DB DC DD BLACK LUNG CONTRIBUTIONS IVD CHILD SUPPORT IVE ADOPTION DUPLICATE IVE ADOPTION NOT DUPLICATE FOSTER CARE - DUPLICATE FOSTER CARE - NOT DS DEPARTMENT OF LABOR JOB EA EF EI EN FP FR GA GI GR EDUCATIONAL ASSISTANCE EMERGENCY FOOD VOUCHER EXCLUDE INDIAN PAYMENT ENERGY ASSISTANCE FEDERAL PENSION FEDERAL RELOCATION GENERAL ASSISTANCE GENERAL ASSISTANCE IN-KIND EDUCATION GRANT COMMUNITY EDUCATION HS HOUSING SUBSIDY DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0012 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 0CATEGORY RC SUBJECT NAME SEQATTR REL KEYWORD 1 * * * * * * * * ________________________________________________________________________________ ________________________________________ ONLY INCOME ONLY ANOTHER STATE RETROACTIVE RETROACTIVE IK IN LA LD LN LP LR LS OA IN-KIND INTEREST DIVIDENDS LOANS - NOT DUPLICATE LOANS - DUPLICATE LUMP SUM NOT COUNTABLE LOAN REPAY PROFITS LOAN REPAYMENT LUMP SUM COUNTABLE OTHER - COUNTABLE CA MA OC OTHER - COUNTABLE UNEARNED OF OG OTHER - COUNTABLE FS ONLY OTHER - COUNTABLE SAGA ON PA OTHER - NON-COUNTABLE UI PUBLIC ASSISTANCE - PI PR RA PRIVATE HEALTH INSURANCE PRIVATE RETIRE SOCIAL SECURITY RB RC RD SSI RETROACTIVE VA RETROACTIVE UNEMPLOYMENT COMPENSATION * Final layout may include additional fields (e.g., client cell phone number). RETROACTIVE RETROACTIVE RETROACTIVE DISABILITY RETROACTIVE SURV BENEFITS AID ATTENDANT BENEFITS BENEFITS ELEMENT 00007/0 CONTAINS RE WORKER COMPENSATION RF RAILROAD RETIREMENT RG SOCIAL SECURITY RH SOCIAL SECURITY RP RR SA SB SD SI SP SR SU SV UC VA RENTAL PROPERTY RAIL RETIRE SOCIAL SECURITY BENEFITS STRIKE BENEFITS SOCIAL SECURITY DISABILITY SOCIAL SECURITY INSURANCE STATE PENSION STATE RELOCATION NON-IVD SUPPORT SOCIAL SECURITY SURVIVOR UNEMPLOYMENT VETERAN'S ADMINISTRATION VI VT VISTA VETERAN'S ADMINISTRATION WC WORKER COMPENSATION WI WOMEN'S AND CHILDREN'S AC CL-MANC-STS-REAS-CD 0 DEN=0452 CODE DESIGNATING THE CLIENT MANAGED CARE STATUS REASON. CODE ---- DESCRIPTION -------------------------- ---------------------------------------1 * * * * * * * * 11/24/10 11:24:31 PAGE:0013 DB/DC DATA DICTIONARY REPORT STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME ________________________________________________________________________________ ________________________________________ RECIPIENT ELEMENT 00001/0 CONTAINS PRIMARY STATUS OF THE CLIENT MANAGED CARE. 303 CLIENT IS AN ELIGIBLE 508 CLIENT LOST ELIGIBILITY AC CL-MANC-STS-CD 0 DEN=0453 CODE DENOTING THE * Final layout may include additional fields (e.g., client cell phone number). STS-REAS-CD. IT IDENTIFIES THE STATUS FIRST CHARACTER OF THE CL-MANCWHICH IS PART OF THE WHOLE 3- CHARACTER CODE. ---------------------------------------- CODE ---3 5 ELEMENT 00002/0 CONTAINS 1 * * * * * * * * DESCRIPTION -------------------------ELIGIBLE NOT ELIGIBLE AC FILLER-002 0 DB/DC DATA DICTIONARY REPORT STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD 11/24/10 11:24:31 PAGE:0015 AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME ________________________________________________________________________________ ________________________________________ STANDARD FILLER ELEMENT OF INDICATED LENGTH. ELEMENT 00010/0 CONTAINS WAS DENIED OR CLOSED. FOR THE ASSOCIATED CLIENT'S STATUS IN THE SET BY ELIGIBILITY DETERMINATION AC CL-AU-STS-REAS-CD 0 DEN=0093 CODE SHOWING WHY AN AU A CODE IDENTIFYING THE REASON ASSISTANCE UNIT. THIS CODE IS TO ADVISE THE ELIGIBILITY WORKER AND FOR USE IN NOTICES TO ADVISE THE CLIENT OF THE REASON THAT AN ASSISTANCE UNIT OR A CLIENT HAS BEEN THE USE OF THESE CODES IS GOVERNED BY SEE THE ELIGIBILITY DECISION TABLES UNDER WHICH EACH CODE IS USED. FOUND INELIGIBLE FOR BENEFITS. THE ELIGIBILITY DECISION TABLES. FOR THE SPECIFIC CIRCUMSTANCES SEE THE ELIGIBILITY DETERMINATION DECISION TABLES AS TO WHICH SUSPENSION OF THE ADVERSE ACTION INELIGIBILITY TO PROVIDE THE AU A FAIR HEARING BEFORE THE NEGATIVE ---------------------------------------- REASON CODES ARE ASSOCIATED WITH PERIOD (I.E., ADVANCE NOTICE OF WITH THE OPPORTUNITY TO REQUEST ACTION TAKES EFFECT). CODE ---- DESCRIPTION -------------------------- * Final layout may include additional fields (e.g., client cell phone number). CITIZENSHIP PURSUE HIGH SCHOOL EDUCATION 21 MONTHS 100 101 102 103 104 105 106 107 108 109 110 FLEEING FELON PAROLE/PROBATION VIOLATOR CONVICTED DRUG FELON GE FAIL MANAGED CARE FAILED CE GE ELIGIBILITY DP INELIGIBLE MONTHS DP RFJF CTR 18-21 DP 3 TIMES LIMIT DP 1 PER YEAR DP FAILED APP MO FOOD STAMPS FAILED 111 112 113 114 115 FAILED EMPLOYMENT TEST FAILED PAYMENT PREMIUM MEDICAL PREMIUM CHARGE TFA CTR GREATER THAN 60 MINOR PARENT FAILED TO 116 FAIL APPEAR ASSESSMENT 1ST 117 FAIL APPEAR ASSESSMENT 118 AF HOUSEHOLD OF ONE 1ST ES 119 AF HOUSEHOLD OF ONE 2ND ES 120 AF HOUSEHOLD OF ONE 1ST VQ 121 AF HOUSEHOLD OF ONE 2ND VQ 122 PERSONAL RESPONSIBILITY & 201 202 203 INVALID LIVING ARRANGEMENT FAILED CITIZENSHIP RECEIVING SUPPLEMENTAL 204 205 NO DEPENDENT CHILD AGE SCHOOL REQUIREMENTS EXTENSION PENALTY PENALTY PENALTY PENALTY WORK OPPORTUNITY ACT NOT SEEK CITIZENSH SECURITY INSURANCE AFDC 206 AGE SCHOOL REQUIREMENTS DS DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0016 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 0CATEGORY RC SUBJECT NAME SEQATTR REL KEYWORD 1 * * * * * * * * ________________________________________________________________________________ ________________________________________ FOOD STAMPS SECURITY NUMBER REQUIREMENT 207 AGE SCHOOL REQUIREMENTS 208 FAILED APPLY SOCIAL 209 210 NOT A REFUGEE FAILED RESIDENCE 211 NOT DEPRIVED * Final layout may include additional fields (e.g., client cell phone number). REQUIREMENT CONNECT 1ST OFFENSE ELIGIBLE CONNECTICUT ENERGY ASSISTANCE PR QUIT CONNECT 1ST OFFENSE CONNECT 2ND OFFENSE CONNECT 3RD OFFENSE 212 213 NO RELATIONSHIP FAILED PREGNANCY 214 215 PREGNANT SPOUSE INELIGIBLE REFUSED PARTICPATION JOB 216 217 218 ADULT PARENT STRIKER MEMBER STRIKER NOT CASH ASSISTANCE NOT 219 PRIMARY EARNER VOLUNTARY 220 221 222 FAILED AGE REQUIREMENT FAILED AABD REQUIREMENT REFUSED PARTICIPATION JOB 223 REFUSED PARTICIPATION JOB 224 REFUSED PARTICIPATION JOB 225 NOT REQUIRE 226 227 INSTITUTIONALIZED PRIOR PENALTY JOB CONNECT 228 229 FAIL COOPERATE WITH CSEB 18 MONTH ELIGIBILITY 230 NO VERIFICATION REQUIRED 231 232 233 234 MEMBER NO VERIFY INFO GUILTY VIOLATION NUMBER PEOPLE CHANGE PRIOR PENALTY JOB CONNECT 235 236 FAILED REAPPLY BENEFIT FAILED MONTHLY REPORT 237 238 239 SHELTER UTILILITY CHANGE MEDICAL EXPENSE CHANGE VOLUNTARY QUIT REDUCE 240 PRIOR PENALTY INTENTIONAL 241 FAILED QUARTERLY REPORT 242 243 244 245 246 247 248 249 ELIGIBLE AFDC ASSIGNED NOT USED MEMBERS LISTED DIED NO ELIGIBLE MEMBERS UNDER PRIOR PENALTY MEMBER UNDER PENALTY NO HEAD OF HOUSEHOLD CONCURRENT RECEIPT CASH 250 CONCURRENT RECEIPT MEDICAL INSTITUTIONALIZED FOOD STAMPS REFUGEE EXEMPTION INFO AFDC DEADLINE EARNINGS PROGRAM VIOLATION FOOD STAMPS DEADLINE ASSISTANCE ASSISTANCE * Final layout may include additional fields (e.g., client cell phone number). STAMPS VERIFICATION MONTH ASSETS FOOD STAMPS 1 * * * * * * * * 251 CONCURRENT RECEIPT FOOD 252 MANDATORY MEMBER NO 253 MONTHLY REPORT CLOSE PRIOR 254 PRIOR PENALTY TRANSFER DB/DC DATA DICTIONARY REPORT STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME 11/24/10 11:24:31 PAGE:0017 ________________________________________________________________________________ ________________________________________ ASSET AFMA OTHER PROGRAM COMPENSATION ABUSE INSTITUTIONALIZED USED 255 PRIOR PENALTY TRANSFER 256 FOOD STAMPS PENALTY FROM 257 INVALID SAGA HOUSEHOLD 258 NO COOPERATION SUBSTANCE 259 SAGA NOT REQUIRED 260 REASON CODE CITED BUT NOT 261 FAIL AF ACTIVITY 1 IN 6 262 263 PROGRAM HAS ENDED DCF NOT ACTIVE / CURRENT 264 IV-E INELIGIBLE /CURRENT 265 266 AF FAIL JOBS REVIEW FS FAIL RETURN CHANGE 267 AF TL DID NOT COME TO 268 269 AF TL NO EXTENSION GRANTED AF EMPLOYMENT SERVICES 270 AF VOLUNTARY QUIT 271 FAILED REAPPLY REVIEW 272 APPLICANT FILED AFTER 273 EXPECTED INCOME ABOVE 274 275 277 REFUSED HEALTH INSURANCE NO SSI 1619 STATUS MOTHER NEWBORN NOT CASH MONTHS MONTH CLOSE MONTH CLOSE REPORT FORM REVIEW EXTENSION 3 EXTENSION 3 EXTENSION DEADLINE LIMIT ASSISTANCE * Final layout may include additional fields (e.g., client cell phone number). RECIPIENT DEPENDENT STUDENT MEDICAL BENEFICIARY MEDICAL BENEFICIARY PART A EMPLOYED FOR QUARTER AGE 1 TO 6 AGE 6 TO 19 1 - FAIR-CHANCE 2 - FAIR-CHANCE 3 - FAIR-CHANCE SERVICE 278 CARETAKER NOT ACTIVE 279 NOT ELIGIBLE QUALIFIED 280 NOT ELIGIBLE QUALIFIED 281 282 CLIENT MA-ID FOR MRF HEAD OF HOUSEHOLD NOT 283 FAIL FAMILY POVERTY LEVEL 284 FAIL FAMILY POVERTY LEVEL 285 REFUSE JOB CONNECT OFFENSE 286 REFUSE JOB CONNECT OFFENSE 287 REFUSE JOB CONNECT OFFENSE 288 289 290 291 292 293 294 295 296 297 298 CHILD SUPPORT ONLY CHANGE VOLUNTARY QUIT OFFENSE 1 VOLUNTARY QUIT OFFENSE 2 VOLUNTARY QUIT OFFENSE 3 REFUSE CHILD SUPPORT 1 REFUSE CHILD SUPPORT 2 REFUSE CHILD SUPPORT 3 REFUSE QUALITY CONTROL 1 REFUSE QUALITY CONTROL 2 REFUSE QUALITY CONTROL 3 FAIL REGISTER FOR JOB 299 301 302 303 SAGA JOB READY TOTAL INCOME ABOVE LIMIT CHILD SUPPORT MORE GRANT EARNED INCOME DEDUCTION DISREGARD CHANGE 304 SPECIAL NEEDS CHANGE DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0018 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 0CATEGORY RC SUBJECT NAME SEQATTR REL KEYWORD 1 * * * * * * * * ________________________________________________________________________________ ________________________________________ 305 306 307 308 309 310 311 312 313 314 315 FA BENEFITS CHANGE UNEARNED INCOME CHANGE EARNED INCOME CHANGE LPSUM INELIGIBLE 2 MONTH LPSUM INELIGIBLE 3 MONTH LPSUM INELIGIBLE 4 MONTH LPSUM INELIGIBLE 5 MONTH LPSUM INELIGIBLE 6 MONTH LPSUM INELIGIBLE 7 MONTH LPSUM INELIGIBLE 8 MONTH LPSUM INELIGIBLE 9 MONTH * Final layout may include additional fields (e.g., client cell phone number). CHANGE CHANGE RECOUPMENT CHANGE GENERAL ASSISTANCE CHANGE 316 317 318 319 320 321 322 LPSUM INELIGIBLE 10 MONTH LPSUM INELIGIBLE 11 MONTH LPSUM INELIGIBLE 12 MONTH LPSUM INELIGIBLE OVER YEAR GROSS INCOME EXCEEDS LIMIT DEEMED INCOME CHANGE CHILD SUPPORT REFUND 323 HOME MAINTENANCE AMOUNT 324 325 326 327 328 NEED STANDARD CHANGE 30 THIRD EXPIRED 30 DOLLAR EXPIRED RECOUPMENT AMOUNT CHANGE MONEY DEDUCTED FOR 329 DEPENDENT CARE EXPENSE 330 331 COUNTABLE INCOME CHANGE NO OTHER INCOME ONLY 332 PERSONAL NEEDS AMOUNT 333 UNEARNED INCOME DEDUCTION 334 335 MOVED DIFFERENT REGION UNCOVERED INSURANCE AMOUNT 336 INCOME DIVERTED SPOUSE 337 338 HARDSHIP AMOUNT CHANGE FOOD STAMPS ADDITIONAL 339 MEDICAL ASSISTANCE 340 341 342 343 APPLIED INCOME CHANGE NO IV E INCCOME G A HAS MEET NEEDS NO DSP BENEFITS AFTER 344 345 BEG REASON FOR AFDC ADMINISTRATIVE BEG REASON 346 UNINTENTIONAL BEG REASON 347 348 FRAUDULENT BEG REASON AABD ADMINISTRATIVE BEG REASON 349 UNINTENTIONAL BEG REASON CHANGE CHANGE CHANGE DENIAL APPLICATION MONTH COVERAGE EXPIRED 09/30/91 AABD AABD FS FS 350 FRAUDULENT BEG REASON FS 351 DISCONTINUANCE 352 CONNECTICUT SHELTER CHANGE 1 * * * * * * * * DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0019 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 * Final layout may include additional fields (e.g., client cell phone number). 0CATEGORY SEQATTR REL KEYWORD RC SUBJECT NAME ________________________________________________________________________________ ________________________________________ SUBSIDY RENT SUBSIDY SUBSIDY SUBSIDY 353 354 355 357 359 360 PAYMENT STANDARD 07/95 SAGA STATE LAW CHANGE AF IVD EXCEEDS GRANT BENEFIT NO CHANGE 07/95 BENEFIT NO CHANGE 07/95 BENEFIT CHANGE LOST RENT 361 BENEFIT CHANGE RECEIVED 367 BENEFIT CHANGE NO RENT 368 BENEFIT CHANGE NEW RENT 370 BENEFIT CHANGE NEW HOUSING 371 BENEFIT CHANGE END HOUSING 372 BENEFIT CHANGE CHANGE 375 EARNED INCOME OVER POVERTY 376 LOST FILL THE GAP 377 ACQUIRE FILL THE GAP 378 379 NUMBER CAP PEOPLE CHANGE FOOD STAMP COMMODITY 401 407 PROPERTY OVER ASSET LIMIT NO COOPERATION INCOME 409 411 412 413 414 415 416 500 DEEM OVER ASSET LIMIT TRANSFER INELIGIBLE 1 MO TRANSFER INELIGIBLE 3 MO TRANSFER INELIGIBLE 6 MO TRANSFER INELIGIBLE 9 MO TRANSFER INELIGIBLE 12 MO TRANSFER INELIGIBLE CALL FICA NOT PAID MEDICAL 501 OVERDUE MEDICAL PREMIUMS 518 NR INELIGIBLE TEMPORARY 519 PRESCRIPTION ELIGIBLE NOT 520 PROGRAM ENDED DUE TO 521 NOT CURRENTLY CONNECTICUT 522 ELIGIBLE FOR MEDICAID SUBSIDY SUBSIDY HOUSING SUBSIDY LEVEL BUDGETING BUDGETING CHANGE ASSET WAGES NOT PAID FAMILY ASSTANCE COUNTER MEDICAL ASSISTANCE ELIGIBLE FEDERAL LAW CHANGE RESIDENT * Final layout may include additional fields (e.g., client cell phone number). MET MET DOCUMENTATION NEEDED RESIDENT DOCUMENTATION NEEDED DOCUMENTATION NEEDED DOCUMENTATION NEEDED AWARDS 523 524 OTHER INSURANCE COVERAGE DISABILITY REQUIREMENT NOT 525 526 527 528 SINGLE INCOME OVER LIMIT COUPLE INCOME OVER LIMIT AGE REQUIREMENT NOT MET RESIDENCY REQUIREMENT NOT 529 530 UNPAID REGISTRATION FEE TIMELY INCOME 531 TIMELY CONNECTICUT 532 TIMELY MARITAL 533 534 APPLICATION NOT SIGNED TIMELY DISABILITY 535 NO RETROACTIVE CONNPACE 536 REGISTRATION FEE CHECK BOUNCED 537 CONNPACE/CADAP CLIENT DIED DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0020 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 0CATEGORY RC SUBJECT NAME SEQATTR REL KEYWORD 1 * * * * * * * * ________________________________________________________________________________ ________________________________________ POVERTY LEVEL CERTIFICATION ELIGIBILITY NEEDED REDETERMINATION NEEDED DOCUMENTATION NEEDED DOCUMENTATION NEEDED APPLICATION ELIGIBILITY LIABLE RELATIVE SUPPORT CONTROL 538 CADAP NET INCOME OVER 539 NO CADAP CLIENT 540 TIMELY CADAP MEDICAL 541 TIMELY CADAP 542 TIMELY DATE OF BIRTH 543 TIMELY INSURANCE 544 550 ELIGIBLE FOR MEDICAID VOLUNTARY WITHDRAWAL 551 552 WHEREABOUTS UNKNOWN FAILED INFO DETERMINE 553 NO COOPERATION LEGALLY 554 555 556 YOU HAVE MOVED APPLICATION OPENED ERROR NO COOPERATION QUALITY 557 AU REQUESTED CLOSURE * Final layout may include additional fields (e.g., client cell phone number). INCOME CLEARANCE ASSET EMPLOYMENT SERVICES PLAN INDIVIDUAL FAMILY GRANT REQUIREMENT DECLARATION SCHOOL DIPLOMA FOURTH EXTENSION PROCESS CERTIFICATION 558 FAILED APPLY PARENTAL 559 CLIENT DISCONTINUED NAME 560 FAILED COOPERATE TO FIND 561 FAIL SHOW APPOINMENT 562 FAILED COOPERATE 563 FAILED SIGN CITIZEN 564 FAILING TO PURSUE HIGH 565 FAIL ELIGIBILITY RULES 566 NO COOPERATION ELIGIBILITY 567 DRUG ALCOHOL LOST 568 FOOD STAMPS ADULT CHILD 569 CHILD ACCEPTED INTO FOSTER 570 571 572 573 CALL YOUR CASEWORKER CEAP MONEY USED WORKER VOIDED APPLICATION F/S WORK REQUIREMENT TIME 574 NOT RESPONSIBLE HEAT 575 NOT RECEIVE CASH 576 577 BORDER NOT ELIGIBLE MISSED APPLICATION 578 579 CEAP NOT COOPERATING GENERAL ASSISTANCE MET 580 NOT AFDC IN 3 OF LAST 6 581 INELIGIBLE DISCOUNT REASON 582 EMPLOYBLE PARENTS LIVE 583 12 MONTH PERIOD OF 584 LEFT JOB WITHOUT GOOD 585 CHILD RECEIVING CARE 586 MEDICAL ASSISTANCE 587 ELIGIBLE FOR PROGRAM BUT 588 CHILD SUPPORT INCOME INELIGIBLE CARE LIMIT SOURCE ASSISTANCE DEADLINE NEEDS MONTHS CODE WITH CHILD ELIGIBILITY ENDED REASON TURNED 13 COVERAGE TRANSFERRED - AU CLOSED IN A DIFFERENT AU GREATER THAN GRANT AMOUNT * Final layout may include additional fields (e.g., client cell phone number). BIOMETRIC 589 NO COOPERATION WITH 590 AF IPV 1 DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0021 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 0CATEGORY RC SUBJECT NAME SEQATTR REL KEYWORD 1 * * * * * * * * ________________________________________________________________________________ ________________________________________ BIOMETRIC B A REQUIREMENTS DISCLOSURE 591 592 593 AF IPV 2 AF IPV 3 AU LEVEL NO COOPERATION 594 NOT ELIGIBLE FOR MEDICARE 595 NOT ELIGIBLE FOR MEDICARE 596 FAILED CITIZEN 597 598 PROGRAM HAS ENDED NO SSN/MEDICARE NUMBER 599 ASSETS EXCEED PROGRAM 600 601 602 603 SAGA SAGA SAGA SAGA 604 SAGA FAIL SUPPLEMENTAL 605 SAGA FAIL IMMIGRATION & 606 607 610 612 613 614 SAGA FAIL TOWN SAGA NOT ELIGIBLE SM AF TL WORKER NO EXTENSION SAGA SAMI INELIGIBLE HUSKY-B REFER FOOD STAMPS ALIEN STATE 615 MEDICAL ASSISTANCE ALIEN 616 617 618 619 620 621 DP DP DP DP DP DP WORK HISTORY MARKETABLE SKILLS PERSONAL BARRIERS PROBLEM OVER 3 MONTHS NEEDS EXCEED GRANT FAIL PROVIDE 622 623 624 625 626 DP DP DP DP NO PREVIOUS FRAUD BENEFIT UNDER 10.00 RESOURCES EXIST UNDUE HARDSHIP TFA HARDSHIP LIMITS INELIGIBLE SECURITY INSURANCE ASSIGN CLIENT FRAUD PA DUAL PART PA TIME LIMIT MAXIMUM PA SANCTION- NATURALIZATION SERVICE ENROLL RESIDENT STATE RESIDENT VERIFICATION * Final layout may include additional fields (e.g., client cell phone number). COMMODITY COMMODITY EXTENSION DENIAL LABOR ORIENTATION DENIAL REASON OVER INCOME LIMIT 627 628 629 630 F09 - NOT ACTIVE CA/MA ES - DISCONTINUED FOOD STAMP ABAWD DEEMOR AU INELIGIBLE FOOD 631 CLIENT INELIGIBLE FOOD 632 633 NON-QUALIFIED HUSKY ADULT AID TO FAMILY THIRD 634 635 SAGA FAMILY INELIGIBLE AF FAIL DEPARTMENT OF 636 EXPEDITED FOOD STAMP 637 638 Q04 DENY DISCOUNT DENY MEDICAL ASSISTANCE - 639 DENY MEDICAL ASSISTANCE - 640 FAIL VERIFYING CITIZENSHIP OVER ASSETS LIMIT DURING REASONABLE OPPORTUNITY PERIOD 641 FAIL VERIFYING IDENTITY DURING REASONABLE OPPORTUNITY PERIOD 1 * * * * * * * * DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0022 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 0CATEGORY RC SUBJECT NAME SEQATTR REL KEYWORD ________________________________________________________________________________ ________________________________________ 642 FAIL VERIFYING CITIZEN 643 FAIL VERIFYING CITIZENSHIP 644 FAIL VERIFYING IDENTITY 645 FAIL VERIFYING CITIZEN 800 801 802 803 804 805 SAGA SAGA SAGA SAGA SAGA SAGA 806 SAGA ANNIVERSARY PERIOD 807 993 SAGA GOOD CAUSE MAXIMUM SAGA CONVERSION RECEIVE 994 SAGA CONVERSION RECEIVE 995 SAGA CONVERSION RECEIVE PA IDENTITY DURING REASONABLE OPPORTUNITY PERI AFTER REASONABLE OPPORTUNITY PERIOD AFTER REASONABLE OPPORTUNITY PERIOD IDENTITY AFTER REASONABLE OPPORTUNITY PERIO MAXIMUM LIMIT SAGA CASH SAGA MEDICAL MEDICAL WORK NO COOPERATION VOLUNTARY QUIT JOB FIRED FROM JOB REFUSE JOB OFFER RECEIVE SSD TIME LIMIT DURATION * Final layout may include additional fields (e.g., client cell phone number). 996 CASH SAGA CONVERSION RECEIVE PA 998 SAGA CONVERSION AC CL-DCF-CAT-CD 0 ELEMENT 00013/0 CONTAINS DEN=0650 CODE. CODE ------------------------------------------NEEDS D F CLIENT DCF CATEGORY DESCRIPTION -------------------------ALL OTHERS FAMILIES WITH SERVICE J JUVENILE JUSTICE V VOLUNTARY SERVICES X DUALLY COMMITTED AC CL-DCF-EFF-DT 1 ELEMENT 00014/0 CONTAINS DEPARTMENT OF CHILDREN AND FAMILIES EFFECTIVE DATE, ANOTHER FORMAT. ELEMENT 00022/0 CONTAINS CHILDREN AND FAMILIES SERVICE RECEIVED AC CL-DCF-SVC-RCVD-CD 0 DEN=0671 CLIENT DEPARTMENT OF CODE. CODE ---- DESCRIPTION -------------------------- ---------------------------------------I IN HOME CARE O OUT OF HOME CARE AC CL-RACE-1-CD 0 ELEMENT 00023/0 CONTAINS DEN=0084 ---------------------------------------- NATIVE PACIFIC ISLANDER 1 * * * * * * * * CLIENT'S RACE CODE. CODE ---- DESCRIPTION -------------------------- A B C N ASIAN BLACK OR AFRICAN DESCENT WHITE / CAUCASIAN NATIVE AMERICAN OR ALASKA P NATIVE HAWAIIAN OR OTHER DB/DC DATA DICTIONARY REPORT STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME 11/24/10 11:24:31 PAGE:0023 ________________________________________________________________________________ ________________________________________ * Final layout may include additional fields (e.g., client cell phone number). 2007. (ASIAN) (BLACK) (CAUCASIAN / HISPANIC) (ALASKAN NATIVE ESKIMO / NATIVE AMERICAN) (CAUCASIAN / HISPANIC) (ALASKAN NATIVE ESKIMO / NATIVE AMERICAN) (PACIFIC ISLANDER) ELEMENT 00024/0 CONTAINS ---------------------------------------- NATIVE NOTE: CODES WERE CONVERTED APRIL A (ASIAN) TO A B (BLACK) TO B C (CAUCASIAN) TO C E (ALASKAN NATIVE ESKIMO) TO N H (HISPANIC) TO C N (NATIVE AMERICAN) TO N P (PACIFIC ISLANDER) TO P AC CL-RACE-2-CD 0 DEN=0084 CLIENT'S RACE CODE. CODE ---- DESCRIPTION -------------------------- A B C N ASIAN BLACK OR AFRICAN DESCENT WHITE / CAUCASIAN NATIVE AMERICAN OR ALASKA P NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 2007. (ASIAN) (BLACK) (CAUCASIAN / HISPANIC) (ALASKAN NATIVE ESKIMO / NATIVE AMERICAN) (CAUCASIAN / HISPANIC) (ALASKAN NATIVE ESKIMO / NATIVE AMERICAN) (PACIFIC ISLANDER) ELEMENT 00025/0 CONTAINS ---------------------------------------- NOTE: CODES WERE CONVERTED APRIL A (ASIAN) TO A B (BLACK) TO B C (CAUCASIAN) TO C E (ALASKAN NATIVE ESKIMO) TO N H (HISPANIC) TO C N (NATIVE AMERICAN) TO N P (PACIFIC ISLANDER) TO P AC CL-RACE-3-CD 0 DEN=0084 CODE ---A B C CLIENT'S RACE CODE. DESCRIPTION -------------------------ASIAN BLACK OR AFRICAN DESCENT WHITE / CAUCASIAN * Final layout may include additional fields (e.g., client cell phone number). NATIVE PACIFIC ISLANDER (ASIAN) (BLACK) (CAUCASIAN / HISPANIC) (ALASKAN NATIVE ESKIMO / NATIVE AMERICAN) (CAUCASIAN / HISPANIC) (ALASKAN NATIVE ESKIMO / NATIVE AMERICAN) 1 * * * * * * * * NATIVE AMERICAN OR ALASKA P NATIVE HAWAIIAN OR OTHER NOTE: CODES WERE CONVERTED APRIL 2007. (PACIFIC ISLANDER) ELEMENT 00026/0 CONTAINS N A (ASIAN) TO A B (BLACK) TO B C (CAUCASIAN) TO C E (ALASKAN NATIVE ESKIMO) TO N H (HISPANIC) TO C N (NATIVE AMERICAN) TO N P (PACIFIC ISLANDER) TO P AC CL-RACE-4-CD 0 DEN=0084 DB/DC DATA DICTIONARY REPORT STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD CLIENT'S RACE CODE. 11/24/10 11:24:31 PAGE:0024 AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME ________________________________________________________________________________ ________________________________________ ---------------------------------------- NATIVE PACIFIC ISLANDER CODE ---- DESCRIPTION -------------------------- A B C N ASIAN BLACK OR AFRICAN DESCENT WHITE / CAUCASIAN NATIVE AMERICAN OR ALASKA P NATIVE HAWAIIAN OR OTHER NOTE: CODES WERE CONVERTED APRIL 2007. (ASIAN) (BLACK) (CAUCASIAN / HISPANIC) (ALASKAN NATIVE ESKIMO / NATIVE AMERICAN) (CAUCASIAN / HISPANIC) A (ASIAN) TO A B (BLACK) TO B C (CAUCASIAN) TO C E (ALASKAN NATIVE ESKIMO) TO N H (HISPANIC) * Final layout may include additional fields (e.g., client cell phone number). TO C (ALASKAN NATIVE ESKIMO / NATIVE AMERICAN) (PACIFIC ISLANDER) ELEMENT 00027/0 CONTAINS N (NATIVE AMERICAN) TO N P (PACIFIC ISLANDER) TO P AC CL-RACE-5-CD 0 DEN=0084 ---------------------------------------- NATIVE PACIFIC ISLANDER CLIENT'S RACE CODE. CODE ---- DESCRIPTION -------------------------- A B C N ASIAN BLACK OR AFRICAN DESCENT WHITE / CAUCASIAN NATIVE AMERICAN OR ALASKA P NATIVE HAWAIIAN OR OTHER NOTE: CODES WERE CONVERTED APRIL 2007. (ASIAN) A (ASIAN) TO A B (BLACK) TO B C (CAUCASIAN) TO C (BLACK) (CAUCASIAN / HISPANIC) (ALASKAN NATIVE ESKIMO / NATIVE AMERICAN) (CAUCASIAN / HISPANIC) (ALASKAN NATIVE ESKIMO / NATIVE AMERICAN) (PACIFIC ISLANDER) ELEMENT 00028/0 CONTAINS H (HISPANIC) TO C N (NATIVE AMERICAN) TO N P (PACIFIC ISLANDER) TO P AC CL-HSP-LATN-ETH-IND 0 CLIENT'S ETHNICITY IS HISPANIC OR LATINO. HISPANIC OR LATINO. INDICATOR DENOTING WHETHER THE 'N' DENOTES THE CLIENT IS NOT 'Y' DENOTES THE CLIENT IS HISPANIC OR LATINO. ELEMENT 00029/0 CONTAINS AC RENEWAL-DT 3 DATE OF RENEWAL, ANOTHER FORMAT. AC WVR-TYPE-CD 0 ELEMENT 00037/0 CONTAINS DEN=0080 WAIVER TYPE. ---------------------------------------INJURY) WAIVER 1 * * * * * * * * E (ALASKAN NATIVE ESKIMO) TO N CODE ---B CODE IDENTITFYING DESCRIPTION -------------------------ABI (ACQUIRED BRAIN DB/DC DATA DICTIONARY REPORT * Final layout may include additional fields (e.g., client cell phone number). 11/24/10 11:24:31 STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD PAGE:0025 AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME ________________________________________________________________________________ ________________________________________ ASSISTANCE) WAIVER CARE PROGRAM) LIMITED SERVICE D I K M O P DEVELOPMENTALLY DISABLED IFS KATY BECKETT MENTAL ILLNESS OPTION 3 PCA (PERSONAL CARE R 1 MENTALLY RETARDED CHCP (CONNECTICUT HEALTH 2 CHCP (CONNECTICUT HEALTH 3 4 PRE-ADMISSION SCREENING CHCP (CONNECTICUT HEALTH CARE PROGRAM) INTERMEDIATE SERVICE CARE PROGRA) DISABLED ELEMENT 00038/0 CONTAINS AC INST-TYPE-CD 0 DEN=0178 OF INSTITUTION THAT THE CLIENT IS IN. SCREEN AND IS USED IN ONLINE EDITS FOR THE CORRECT INSTITUTION/VENDOR NUMBER IS CODE DENOTING THE KIND THIS FIELD APPEARS ON THE 'INST' THAT SCREEN TO MAKE SURE THAT ENTERED ON THE 'INST' SCREEN. CODE ---- DESCRIPTION -------------------------- ---------------------------------------WAIVER ELEMENT 00040/0 CONTAINS INDICATED LENGTH. ELEMENT 00620/0 WITH BH CW BOARDING HOME HOME COMMUNITY BASED MP MONEY FOLLOWS PERSON NH NURSING HOME PM POST MONEY FOLLOWS PERSON AC FILLER-011 0 STANDARD FILLER ELEMENT OF AC CL-MANC-EFF-DT 0 UNPACKED MANAGED CARE EFFECTIVE DATE ELEMENT 00628/0 WITH AC CL-TPL-POLICY-INFO 0 THIRD PARTY LIABILITY POLICY INFO. ELEMENT 00001/0 CONTAINS AC CL-TPL-CARR-NUM 0 GROUP ITEM CONTAINING CLIENT * Final layout may include additional fields (e.g., client cell phone number). INSURANCE COMPANY WITH WHICH THE CLIENT PROGRAMS ARE ALSO IDENTIFIED WITH RESERVED IDENTIFIABLE BY 'MDA', 'MDB', 'RRB' AND NUMBER UNIQUELY IDENTIFYING THE HAS A HEALTH INSURANCE POLICY SPECIAL FEDERAL INSURANCE CARRIER NUMBERS. THESE ARE 'BLG' THE FIRST THREE CHARACTERS OF THE NUMBER. ELEMENT 00006/0 CONTAINS AC CL-TPL-CARR-NAME 0 APPEAR ON AN MA ID. ELEMENT 00031/0 CONTAINS AC CL-TPL-PLCY-EFF-DT 2 PARTY LIABILITY POLICY FOR THIS CLIENT, ELEMENT 00039/0 CONTAINS THE NAME OF A TPL CARRIER TO EFFECTIVE DATE OF THE THIRD ALPHANUMERIC FORMAT. AC CL-TPL-PLCY-EFF-END-DT 2 THE TPL POLICY EXPIRATION DATE, ALPHANUMERIC FORMAT. ELEMENT 00047/0 CONTAINS AC CL-TPL-PLCY-INDIV-NUM 0 THE INDIVIDUAL'S POLICY NUMBER CARRIED ON A HEALTH INSURANCE POLICY POLICY WITH THE HEALTH INSURANCE CARRIER. ELEMENT 00060/0 CONTAINS THAT UNIQUELY IDENTIFIES THE AC CL-TPL-PLCY-GRP-NUM 0 THE GROUP NUMBER UNIQUELY IDENTIFYING THE GROUP THROUGH WHICH 1 * * * * * * * * DB/DC DATA DICTIONARY REPORT 11/24/10 11:24:31 PAGE:0026 STRUCTURE REPORT FOR: SEGMENT AC HIPAA-EXTRCT-RECORD 0 0CATEGORY RC SUBJECT NAME SEQATTR REL KEYWORD ________________________________________________________________________________ ________________________________________ HELD ELEMENT 00998/0 WITH ELEMENT 01008/0 WITH NAME SUFFIX. ELEMENT 01018/0 WITH ELEMENT 01028/0 WITH NAME PREFIX. A HEALTH INSURANCE POLICY IS AC CL-LAST-NAME-SUFX 0 CLIENT LAST NAME SUFFIX. AC AR-LAST-NAME-SUFX 0 AUTHORIZED REPRESENTATIVE LAST AC CL-FRST-NAME-PRFX 0 CLIENT FIRST NAME PREFIX AC AR-FRST-NAME-PRFX 0 AUTHORIZED REPRESENTATIVE FIRST * Final layout may include additional fields (e.g., client cell phone number). ELEMENT 01038/0 WITH AC TRN-ID-NUM 0 GROUP LEVEL TRANSACTION IDENTIFIER FOR HIPAA EXTRACT ELEMENT 00001/0 CONTAINS AC BTCH-CYC-DT 1 UNSIGNED, UNPACKED BATCH CYCLE DATE CURRENT BATCH CYCLE DATE OF EMS. AC TRN-SEQ-NUM 1 ELEMENT 00009/0 CONTAINS HIPAA TRANSACTION SEQUENCE NUMBER. ELEMENT 00017/0 CONTAINS AC FILLER-014 0 STANDARD FILLER ELEMENT OF INDICATED LENGTH. ELEMENT 01038/0 WITH ELEMENT 01068/0 WITH R AC BTCH-CYC-DT 1 AC VNDR-FED-TAX-NUM 1 THE FEDERAL TAX NUMBER ASSIGNED TO THE VENDOR, TO BE USED FOR 1099 REPORTING. UNSIGNED, UNPACKED VERSION FOR HIPAA TRANSACTIONS. ELEMENT 01077/0 WITH HOUSEHOLD OF THE ASSISTANCE UNIT. AC AU-HOH-FIRST-NAME 0 THIS THE CLIENTS NAME BUT IS BEING CARRIED CONSIDERATIONS ELEMENT 01089/0 WITH ASSISTANCE UNIT HEAD OF HOUSEHOLD MIDDLE INITIAL BUT IS BEING PERFORMANCE REASONS ELEMENT 01090/0 WITH HOUSEHOLD OF THE ASSISTANCE UNIT. NAME OF THE CLIENT BUT IS BEING PERFORMACE CONSIDERATIONS ELEMENT 01109/0 WITH ELEMENT 01119/0 WITH ELEMENT 01129/0 WITH THE FIRST NAME OF THE HEAD OF INFORMATION IS REDUNDANT WITH REDUNDANTLY FOR PERFORMANCE AC AU-HOH-MIDDLE-INIT 0 THE MIDDLE INITIAL OF THE THIS IS THE SAME AS THE CLIENTS CARRIED REDUNDANTLY FOR AC AU-HOH-LAST-NAME 0 THE LAST NAME OF THE HEAD OF THIS IS THE SAME AS THE LAST CARRIED REDUNDANTLY FOR AC HOH-LAST-NAME-SUFX 0 HOH LAST NAME SUFFIX AC HOH-FRST-NAME-PRFX 0 HOH FIRST NAME PREFIX AC EOFAM-IND 0 * Final layout may include additional fields (e.g., client cell phone number). END OF FAMILY INDICATOR: NOT USED. ELEMENT 01130/0 WITH AC PROG-SRC 0 SOURCE OF DATA: NO LONGER USED. AC AU-NUM 1 ELEMENT 01136/0 WITH ALTERNATE PICTURE OF AU-NUM (UNSIGNED, UNPACKED) EMS-GENERATED UNIQUE NUMBER THAT IDENTIFIES AN ASSISTANCE UNIT. THIS DATA ELEMENT IS A PRIMARY KEY TO THE AU DATABASE. ELEMENT 01145/0 WITH INDICATED LENGTH 1 * * * * * * * * AC FILLER-035 0 STANDARD FILLER ELEMENT OF DB/DC DATA DICTIONARY REPORT STRUCTURE REPORT FOR: SEGMENT 0CATEGORY SEQATTR REL KEYWORD AC HIPAA-EXTRCT-RECORD 0 RC SUBJECT NAME 11/24/10 11:24:31 PAGE:0027 ________________________________________________________________________________ ________________________________________ ELEMENT 01180/0 WITH CARE CASE MANAGEMENT INFO - NOT USED. ELEMENT 00001/0 CONTAINS AC PCCM-GRP 0 GROUP ITEM CONTAINING PRIMARY AC PCCM-PRVDR-NM-QUAL-TYP 0 TYPE OF QUALITY CARE THIS PRIMARY CARE CASE MANAGENT PROVIDER CAN DO. ELEMENT 00002/0 CONTAINS AC PCCM-PRVDR-NM-ID 0 PRIMARY CARE CASE MANAGEMENT PROVIDER. ELEMENT 00012/0 CONTAINS AC PCCM-PRVDR-REL-CD 0 IDENTIFICATION CODE OF NAMED RELATIONSHIP CODE OF PRIMARY CARE CASE MANAGEMENT PROVIDER. ELEMENT 00014/0 CONTAINS AC PCCM-PRVDR-CITY-ADDR 0 PROVIDER'S CITY. ELEMENT 00044/0 CONTAINS AC PCCM-PRVDR-ST-CD 0 PROVIDER'S STATE CODE. ELEMENT 00046/0 CONTAINS AC PCCM-PRVDR-ZIP-CD 0 PROVIDER'S ZIP CODE. ELEMENT 00051/0 CONTAINS AC PCCM-PRVDR-TEL-NUM 0 PRIMARY CARE CASE MANAGMENT PRIMARY CARE CASE MANAGEMENT PRIMARY CARE CASE MANAGEMENT * Final layout may include additional fields (e.g., client cell phone number). PRIMARY CARE CASE MANAGEMENT PROVIDER'S TELEPHONE NUMBER. ELEMENT 00061/0 CONTAINS AC PCCM-PRVDR-EFF-DT 2 PROVIDER'S EFFECTIVE DATE, ANOTHER FORMAT. ELEMENT 00069/0 CONTAINS AC PCCM-PRVDR-CHG-REAS-CD 0 PROVIDER'S CHANGE REASON CODE. ELEMENT 00071/0 CONTAINS AC FILLER-020 0 INDICATED LENGTH ELEMENT 01270/0 WITH PRIMARY CARE CASE MANAGEMENT PRIMARY CARE CASE MANAGEMENT STANDARD FILLER ELEMENT OF AC EOR-CON 0 END-OF-RECORD CONSTANT ________________________________________________________________________________ ________________________________________ REASON CODE LEGEND: 0 R - SUBJECT APPEARS EARLIER IN REPORT * * * END-OF-REPORT * * * * Final layout may include additional fields (e.g., client cell phone number).